Resident International Grant Botswana Rotation Pre-Departure Handbook

Education and Volunteers Abroad Committee (EVAC) American Academy of Dermatology Program Directors: Carrie Kovarik, MD; Victoria Williams, MD; Amy Forrestel, MD

INDEX Page INTRODUCTION 2 Code of Conduct 3 Quick Reference Page 4

PRE-DEPARTURE & TRAVEL Pre-Travel Checklist 5 Medical Evacuation Insurance 6 Immunizations & Health 6 Confirming Housing 6 What to pack 6 Travel & Arrival 7 Orientation & Licensing 8

END OF ROTATION End of Rotation Checklist 9

DURING ROTATION Information for Living in Botswana About Botswana 9 Daily Life 10 Liza Rissik, Administrator 10 Cell phones / Internet 10 Our flats and communal living 10 Money matters 11 Transportation 11 Safety 11

Intro to Clinical Work in Botswana Introduction 12 Learning Objectives and Expectations 13 The Setting – Princess Marina Hospital 15 Rotation Structure 15 High Yield Prep Work 17 Background of Dermatology in Botswana 17

APPENDICES 1. Entertainment and Travel 19 2. About Botswana 23 3. Language (Setswana) 26 4. HIV in Botswana 27 2

INTRODUCTION

Dumela! (Hello) Congratulations on receiving the AAD Residents’ International Grant (RIG) to participate in the dermatology elective at Princess Marina Hospital in Gaborone, Botswana. The rotation operates under the umbrella of the Botswana-UPenn Partnership – which is a multidisciplinary collaboration. We are so pleased that you have chosen to be a part of this wonderful experience!

There are two Handbooks for this rotation. 1. The Pre-departure Handbook (this one). Read this thoroughly as soon as possible. It will help you get ready for the trip, get settled to life in Bots, and introduce you to basics of clinical care. 2. The Clinical Guide. Read this prior to departure. It contains VERY detailed information meant to be a reference for your clinical practice. Reading it beforehand is necessary to make your training week a success, but do not try to memorize the details.

These two guides contain a LOT of information, and the rotation can be daunting as you are preparing to go. Just keep in mind: • Most of the information will become clear when you arrive and have your week of training (that is why the overlap week exists!) • You have a whole team to support you. You will be challenged and operating more independently than much of your residency training, but you will never be alone. • On this rotation you will work hard, take care of sick patients in a resource-limited setting (with all of the reward and frustration this entails), grow as a physician, and have fun!

The RIG In an effort to promote international educational opportunities, the AAD, through the Education and Volunteers Abroad Committee (EVAC) provides funding for fifteen U.S. and Canadian senior dermatology residents to participate in an elective rotation in a developing country.

The RIG has been sending U.S. residents to Botswana since 2008. These residents have provided a continuous source of dermatologic care to thousands of patients in the public sector of Botswana. The residents have also been an invaluable educational resource for the Batswana medical students, residents, and faculty.

The rotation is a 4-6 week block based on the timing preferences stated on your application. The goal is to have at least a one-week overlap between residents, which will be used for training and sign-out. The clinical and teaching responsibilities of the rotation are detailed in this handbook.

Non-Penn grant recipients will receive:: • Airfare booked through the AAD Travel Desk • $1700 stipend to cover room and board, evacuation insurance (discussed below), and other needs.

Penn grant recipients will receive: • Airfare booked through the AAD Travel Desk • $1200 stipend to cover room, board, and other needs. The remaining $500 comes from the Kramer Penn Gift Account.

Grant requirements (all covered in more detail later in this handbook) include: AAD Patient log Updated online copy of the patient/biopsy log. Lectures given uploaded to the Google drive Rotation summary/report

The Staff The rotation is run by:

• Dr. Carrie Kovarik. Director of the AAD Resident International Grant Program, and Assoc. Professor of Dermatology, Dermatopathology and ID at the University of Pennsylvania (UPenn). • Dr. Victoria (Tori) Williams, Co-Director of the AAD Resident International Grant Program, Assist. Professor of Derm at UPenn, Site Director of the BUP Derm Rotation, Senior Lecturer at the University of Botswana and former on-site Ministry of Health of Botswana Dermatology Specialist. • Dr. Amy Forrestel, Assist. Professor of Derm at UPenn, Co-Director of the BUP Derm Rotation.

Dr. Kovarik/Dr. Williams coordinate your trip and Dr. Kovarik provides remote dermatopathology consultation. Dr. Williams / Forrestel will be supervising your rotation remotely (or in person if you rotation overlaps with their time on the ground in Botswana). They are there for support inside and outside the hospital… if you need anything, reach out!

Other members of the team: • Dr. Bwanali Jereni is the local full-time dermatologist at Princess Marina Hospital since October 2018. He is the Clinic Director and provides on-site resident supervision. • Breon Smith – Resident International Grant administrative assistant at the AAD • Liza Rissik – BUP administrator in Botswana. She is a wonderful resource who goes above and beyond to act as residents main ‘go to’ on the ground for issues that come up outside the hospital.

Code of Conduct

While in Botswana, you will be representing not only yourself but also the UPenn, the Botswana- UPenn Partnership, and the AAD. Errors in judgment or conduct in Botswana could result in compromising the entire program. You are all adults and will not be monitored. It is up to you to think carefully about the potential negative implications of questionable behavior both in and out of the clinic. So, have fun but please don’t do anything dangerous or dumb.

Additionally, the communal living in the flats requires its own code of conduct. One of the true benefits of this elective is the opportunity for faculty, fellows, residents, and students to interact in an extremely informal way. Please be considerate and flexible when it comes to living arrangements.

Things to remember: • Your actions, intentional or unintentional, have implications for the entire program. • You live communally. Be mindful of the “rules of the flats” (see section below) • Being nasty or aggressive in nearly any setting in Botswana is unlikely to further your cause and may result in your being sent home early. • You are living in a developing country in Africa, and may not have all of the luxuries available in the U.S. Please be flexible. The accommodations are a higher standard than most people have in Bots, and are safe and comfortable.

QUICK REFERENCE SHEET

Pilane court address: Plot 154/155, Ext 9,Gaborone.

Contact List Botswana-UPenn Partnership – Philadelphia Office Victoria (Tori) Williams, Director of BUP Derm Program, Co- Director of [email protected] MD AAD RIG, Asst Prof of Derm at UPenn. Cell: +18327520738 Previous full time local Site Director of Dermatology at PMH. Amy Forrestel, MD Co-Director BUP Derm Program. [email protected] Asst Professor of Dermatology at UPenn Cell: +18138427357 Carrie Kovarik, MD Director of the AAD RIG, Assoc Prof of Derm, [email protected] Dermpath and ID at UPenn Botswana-UPenn Partnership – Gaborone Office Liza Rissik BUP Administrator [email protected] Student, Resident and Visitor Coordinator (+267) 73874486or 72945812 Corrado Cancedda, MD BUP Director Emmanuel Thamage BUP Admin, obtains Waiver Certificates [email protected] Other Important Contacts Bwanali Jereni, MD Local dermatologist at PMH [email protected] +265 884 56 33 10 Dr.Mohan UB Pathologist [email protected] Narasimhamurthy, Breon Smith RIG Administrative Assistant at AAD [email protected] Khunong BUP Driver Cell 71481155 David BUP Driver Cell 74146934 Deluxe Cabs Reliable cab company 71300074, 73595919 Samson Reliable cab driver commonly used by residents 71742778 Main Outreach Clinic Contacts Dr. Farrar Mochudi main contact to set up lectures 72527079 [email protected] Dr. Onyach Alternative contact. Chief Medical Officer 7186 0095 [email protected] Dr Mahbub Alternative contact. 7141 9490 Dr Mungandi Kanye – Acting CMO 77018844 [email protected] Dr. Romero Lobatse – CMO. contact to set up lectures 76022559 Dikgang (Dr. Lebo) Medical officer 71421006 Dr. Leoge Superintendent Landline 5315623, 5315669 Dr. Moshabesha 76208649 Talane OPD Nurse 75321104 Mahika Nurse 71657351 Dr. Khumalo Mahalapye – main contact 74232334 [email protected] Dr. Tshitenge Alternative contact. Family Medicine 71550036 Dermatology phone 1 (iphone) 77583003 Dermatology phone 2 (Nokia) 73282498 / 2331 (from hospital) Princess Marina Hospital 3621400 x 1525 (room 4), x1527 (room 5) Pharmacy 1636/1531

PRE-DEPARTURE AND TRAVEL

PRE-TRAVEL CHECKLIST. Further details are explained after the checklist.

Now. Reach out to your home institution to start the logistical coordination and approval process. Institutions have unique, specific requirements for resident training agreements (RTAs), legal documentation, etc. Sometimes this can take many months to coordinate. Ask your program coordinator or director whom to contact about this and start these discussions NOW. It is your responsibility to get institutional approval for your rotation. Now. Check your passport. It must be a) valid, b) does not expire for at least 6 months following your intended return, and c) have at least 3 consecutive blank pages. Now. Visa. U.S. citizens do not need a visa. If you are not a US citizen, check immediately with the Botswana embassy (http://www.botswanaembassy.org/) whether you need a visa, as the process can take some time. Now. AAD release. Complete and return the release to Breon Smith [email protected] Now. Contact Drs Williams / Forrestel if you do not have a computer that you can bring to Botswana ASAP. Read Pre-Departure Handbook ASAP. Set the exact travel dates. Your RIG acceptance letter tells you the date of your rotation. Choose your exact dates of travel and email Dr. Carrie Kovarik for approval. You should arrive the Saturday or Sunday before your rotation starts. If you plan to extend your stay in Africa in order to travel, all extended travel must be done AFTER the rotation is complete. ASAP. Book flights. Email Breon Smith (AAD admin [email protected]) for instructions to book flights through the AAD Travel Agency, which will then be approved by Carrie Kovarik, ** If flying through Johannesburg, we rec. at least a 2 hour layover. Also, for the flight from Johannesburg to Gaborone, South African Air may be more reliable than Air Botswana, so choose this if it is an option ASAP. Medical evacuation insurance. Penn Residents are covered by Penn’s ISOS insurance. • If your institution provides medical evacuation insurance, obtain the information. • Otherwise, purchase insurance Make travel clinic appointment (if available) and get recommended immunizations / medications. ≥ 3 months prior to departure. Confirm housing and transport from the airport. Email Liza Rissik (the administrator in Botswana) your travel itinerary. She will schedule a driver to pick you up at the airport. Copy the itinerary to Carrie Kovarik so she can be sure it has gone out to Liza. Look at these now (some may take time to get depending on your situation). Gather documents for your Botswana Medical License and Exemption Certificate Application o It is difficult and expensive to get items notarized in Botswana, so do this prior to departure. Without these documents, you cannot see patients. o CARRY ON THESE DOCUMENTS – do not place them in checked luggage for the flight o 4 x passport photos – these should be identical (do NOT notarize these) o 3 x Notarized copy of passport o 2 x Notarized copy of medical school diploma (NOTE: If your diploma is written in Latin, it should be translated to English and then notarized.) o 2 x Notarized copy of your state license. If your state does not provide a formal license to residents, please provide any documentation you have been issued, and a letter from a ranking administrator (eg program director, chair of the department, etc) on letterhead, confirming that you are indeed a resident physician practicing under the institution of XX, in a state that does not issue license cards. If you have a hospital DEA, bring a notarized copy of that. o Copy of your resume / CV o ORIGINAL SIGNED letter of rec from Dr. Kovarik (must be dated within 3 months of departure). o 2-3 months prior to depart. email Carrie with your home address and she will mail this to you. Please scan or make a copy of this letter in addition to all your other documents for credentialing. o ORIGINAL SIGNED letter of recommendation from your program director (must be dated within 3 months of your departure) that was used for the AAD grant application. o Copy of the formal acceptance letter to the RIG program (which was mailed to you by the AAD) 1 month prior to departure, scan a notarized copy of your passport and email it to Emmanuel Thamage ([email protected]) and cc: Dr. Forrestel Orientation call. You will be emailed to schedule an orientation call 1-2 months prior to departure. If you have not heard one month prior, email Drs Forrestel and Williams to schedule a call. 2 weeks prior to departure: email the resident currently in Botswana to ask which supplies are needed at [email protected]

Purchase travel insurance (strongly encouraged) Register your travel plans with the Department of State: https://travelregistration.state.gov/ibrs/ Unlock your iPhone / mobile device (if you wish to have a personal phone in addition to the derm phones)

Medical Evacuation Insurance Recipients will be required to purchase medical evacuation insurance, such as International SOS ($130 per trip) or Medjet Assist ($235 per year if bought through the AAD). You will pay for this out of the AAD stipend. If your medical school provides medical evacuation insurance free of charge to students (ie Penn), you do not need to purchase this; however, you must show proof of coverage to the AAD. If you are a Penn resident, you must register your trip on Penn’s Global Activity Registry (GAR). This step pre-authorizes you to use ISOS and you can access the ISOS membership card and details for Penn. You can register for the GAR here: https://global.upenn.edu/travel-guidance/register-your-trip.

Visa US passport-holders do not need a visa. If you are traveling on a non-US passport, you may need a visa. Please check the up to date guidelines at http:www.botswanaembassy.org/

Immunizations and health • Make an appointment with the travel clinic at your university, if there is one. Up to date medical information on traveling to Botswana can be found on the CDC website: https://wwwnc.cdc.gov/travel/destinations/traveler/none/botswana • Recommended vaccinations: hepatitis A, hepatitis B, typhoid (IM or oral), and ensure Td is up to date. • Malaria prophylaxis: If you plan to travel to the Delta, Chobe or any other place up north, you will need to bring malaria prophylaxis. Gaborone and Francistown are free of malaria. • HIV post-exposure prophylactic medications for needle sticks • You should have a tuberculin skin test before and 6 – 8 weeks after the trip. • The water is generally safe to consume in Gabs and Francistown, except when droughts are severe.

Confirm housing RIG residents stay in BUP housing (called Pilane Court) at a rate of $40 / night. Email Liza Rissik (the administrator in Botswana) your travel itinerary to secure your stay. • For Penn residents: the FIRST $500 will be paid by the Kramer Penn Gift Account, the remainder will come out of your AAD stipend which you will pay with credit card once you arrive in Bots • For non-Penn residents: the entire amount comes of your stipend. You pay with credit card on arrival.

What to Pack Clothes • Dress in Gaborone is “westernized.” Pretty much anything decent is acceptable socially. • Remember, in the US summer (Botswana winter), nights can get quite cold. Bring warm layers (fleece, sweater, beanie, scarf, etc.) • The maids do laundry – don’t overpack clothes. Turnaround time 1-2 days during week. Clothes are ironed and a heavy laundry detergent is used, so keep this in mind when choosing clothes. Some people pack clothes they plan to leave for the maids or give to orphanages. • Work clothes may be casual but neat. Some of the male physicians do wear a tie, most do not. Women wear slacks or skirts. You do not need a white coat. NO SCRUBS. • You are likely to share your flat and your room. You may wish to pack a robe or sleepwear. • Note: people dress up nicely for clubs and residents often go out for nice dinners, so having clothes can be helpful. Electronics • Botswana voltage is 220 volts, not 110. Most elaborate equipment (computers, digital cameras, etc.) have internal converters that will work with both voltages, but small appliances like hair dryers will not work in Bots unless they can be switched to 220. • Adaptors - both Type G and type M plugs

o Type G plugs – most common. Found on most universal adaptors. o Type M plugs - also common. Usually NOT found in universal adaptors. • Laptop. You will need a laptop for this rotation for clinical work. Contact Dr. Williams/ Forrestel prior to your rotation if it is not possible for you to bring one. • VGA Adapter. For your presentations, sites often provide a projector with VGA input. Bring an adaptor - VGA to whatever output your computer has, e.g. HDMI, lightning, etc). • Camera for personal use (clinic Iphone is used for patient photos). • Flash drive Equipment for clinic • Dermlight or other light for clinical exams • If allergic to latex, bring non-latex gloves (not available in the hospital) • Do not bring any expired supplies or medications. Other helpful things • Flashlight or camping headlamp • Small notebook to write down patient information/to do lists • Hat and sunscreen, of course! • Eyedrops/nasal spray because of the dust • Swimsuit and flipflops for the pool at Pilane if in the hot season • Luggage lock for checked bags and larger carry-ons • Lock for lockers at Pilane Court • Extension cord with several U.S. plug outlets on the end – lets you plug in multiple things with one adapter

Do not despair if you forget something; you can find nearly everything in Gabs. (Women should note that sanitary napkins and tampons are easily purchased in Gaborone.) Don’t overpack!

How to Pack - Checked Luggage vs Carry-On • THEFT AND LOST/DELAYED CHECKED BAGGAGE IS A RISK WHEN TRAVELING TO BOTS. DO NOT CHECK ANYTHING THAT ARE VALUABLE OR ABSOLUTELY NECESSARY. • Items for carry on include: your documents for medical licensing, medications, computer, etc. Also carry on at least one change of clothes, in case your baggage arrive days after you do. • Lock your checked bags with a TSA approved lock. Consider bringing a lock for your carry-on bag too, since it may be taken from you just before boarding the small plane to Gaborone from Joburg. • You can plastic wrap checked bags if you are departing from JFK • You can plastic wrap your checked bag on the return trip at the Gaborone airport to deter theft. • Make an inventory of items in checked baggage to aid in claims processing if theft occurs

TRAVEL AND ARRIVAL

Johannesburg Layover Most flights to Gaborone connect through the Johannesburg airport. When you arrive in Johannesburg airport: Follow the signs for international transfers. Have all of your travel documents (passport, itinerary, baggage claim forms) on you in case you need to show Gaborone as the final destination for you or your bags. If you do not have your boarding pass, there is a counter with the airline name on a small TV above an airport attendant. Once you get your boarding pass you will go through security. The gates are down a large escalator and a bus will take you to your plane on the tarmac. You should leave AT LEAST a two hour layover in Jo’burg to improve the odds of having your luggage arrive when you do.

Arrival at Gaborone Airport • Immigration o When you land, you will complete an immigration form. This asks the physical address where you will be staying - Pilane Court, Plot 154/155, Ext 9, Gaborone

o Check the box that states you are there as a “BUSINESS” o It asks for the amount of days you will be in the country. You are allowed 90 days per year without a visa. o Be prepared to answer questions at the passport control counter about how you know Liza Rissik and the purpose for your trip • Baggage claim and customs: Proceed to the baggage claim area and retrieve your bags. Once you have your bags there will be a counter for ‘items to claim’ and ‘no items to claim’. If you do not have anything to declare, you do not need to fill out a customs form. If you have gifts they will ask you for a receipt, and for gifts valued over a certain amount, you pay VAT (taxes). Your bags may be searched. It is best to say you are not carrying any “gifts” or “new items.” Getting money. After customs there is a currency exchange office and an ATM. ATM's are generally the cheapest way to get Pula. The driver can take you to a reliable one in the city on the way from the airport if the airport one has high fees; you can withdraw up to 2500 Pula at a time. If you have a Bank of America debit card, you can use the Barclays ATMs without paying a transaction fee. There are ATMs in Main Mall within walking distance of Pilane Court.

Airport Pickup There is no public transport available from the airport!! But there are taxis available if you need one. Liza Rissik arranges a BUP driver to pick you up. The driver will likely be David (Cell 74146934) or Khunong (Cell 71481155). They will be waiting with a Botswana-UPenn Partnership sign after baggage claim. There is no charge for the transportation and a tip is not expected; however, if you feel your service is beyond expectations, you can leave a tip if you like. Especially if your flight has been delayed or canceled and the driver waited at the airport until your arrival. For example, you can buy them a sandwich or food item as a thank you. The driver will have the keys to Pilane and after dropping you off, the driver will set a time to come pick you up again Monday morning to take you to the BUP office for orientation. Please call/text Liza Rissik if you encounter any delays. If you do get stuck at the airport in Gabs, try to call Khunong or David (phone numbers above), or take a van to the Avani Hotel, which is near the flats, and try to get in touch with Liza Rissik, Khunong, or David from there. You can also try one of the taxis. Make sure to establish your price before getting into the car. To get to Pilane Court, near Main Mall, is about 100 BWP to 120 BWP ($10-12). You will need cash to pay for this.

Orientation and Licensing • To work in Bots, all physicians must a) register with the Botswana Health Professions Council (BHPC), and b) obtain a waiver/exemption certificate from the Dept of Immigration. Registrations are processed only on Mondays and Tuesdays. • The first Monday of your rotation, bring all of your documents for your license and waiver to the office and 30 pula to pay for the government processing fee. Liza Rissik will provide a general orientation then help you to fill out the BHPC Application form as well as the exemption / waiver form. A driver then takes you to the BHPC office to drop off your forms (this requires 30 pula). Wednesday afternoon, you will return in person to the BHPC office for swearing in. If you did not pay on Monday, bring 30 pula on Wednesday. The physical license is available for pickup on Thursday afternoon.

END OF ROTATION

CHECKLIST FOR THE END OF THE ROTATION

Ensure your teaching lectures have been uploaded to the google drive folder entitled “Lectures”. Email next rotating resident at least 2 weeks before their departure to update them on what supplies are running low in clinic - contact list of all residents found on Google Drive under “RIG Stuff” folder Email Carrie Kovarik and Breon Smith the following: 1. Final patient log and updated biopsy log (Sending via secure email is best for the log). 2. One page trip report/rotation summary - including a specific patient encounter experience, a description of what you gained from the experience and a photo of you during your rotation. Please do not include photos with identifiable patients. Please also include any suggestions for improvement of the program. Create one detailed PowerPoint presentation on a good case you saw in Botswana & upload it to the Google Drive under “Teaching Module.” The goal is for it to be a teaching case that we can use to teach incoming RIG residents and local students / residents. Teaching points can be: - Bread and butter derm diagnoses with good photos; - Rare derm diagnoses; - Points about navigating the system or how to use limited resources available; - Anything else you think would be interesting It is OK if you did not see the patient yourself, for example, if you saw a patient in follow up after disease resolution, a complex patient following up, a biopsy that just came back, etc. Update the Predeparture Handbook and Clinical Guide with suggestions (using tracked changes) based on your experiences, and email to Drs. Williams and Forrestel. Check that all albino patients seen during your rotation were added to the sunscreen registry tab in the patient log. Post-trip tuberculin skin test - 8 weeks after returning

DURING ROTATION

LIFE IN BOTSWANA / GABORONE

About Botswana and Gaborone Botswana was formerly a British protectorate known as the Bechuanaland Protectorate. It received its independence in 1966, and at that time, the name was changed to Botswana. Botswana is now a parliamentary republic. Education and healthcare are free; and the national literacy rate is above 80%.

Gaborone is the capital city -- pronounced “Ha-bor-ron-ee”…g’s are pronounced as h’s in Botswana, e’s are not silent… also called “Gabs” by expats. It is located in the southeastern corner of Botswana, a mere 9 miles (15 km) from the South African border. It combines feelings of both rural Africa with tin roofed houses and high-rise office buildings. There are modern malls but few sidewalks and street lighting.

Language, Greetings, & Respect English is the official language, but Setswana is the national language and is widely used (79%). Many older Batswana only speak Setswana. It is very important in Batswana culture to greet everyone before you begin a conversation. People usually greet one another by saying hello (even strangers). “Dumela mma” (to a woman) or “Dumela rra” (to a man) is the minimum Setswana everyone should learn.

Recognition is very important to Batswana and to ignore even a greeting is considered very rude. Also be aware that seniority and age carry a lot of weight in Botswana.

For more information on Botswana and Setswana (as well as key Setswana phrases), see the Appendices.

DAILY LIFE IN BOTSWANA

CARS DRIVE ON THE LEFT-HAND SIDE – WATCH OUT WHEN CROSSING THE STREET!!!!

Liza Rissik: Liza Rissik is our administrator in Botswana. She is organized, committed, and resourceful. She is very willing to be helpful, so do not hesitate to go to her with problems or questions. However, remember that she is not your mother – be courteous. Thank her!

Cell phones Cellular service in Botswana is generally very affordable and reliable. Botswana’s country code is +267. To dial the US - dial US country code (“001”) + the number. • You will be provided two Derm phones during your stay. If you’re lucky, the resident you are overlapping with will be at the flats when you arrive and you can get the phone immediately. o Derm Phone 1 – (+267)73282498 (this is a small Nokia and the line also functions as a speed dial from the hospital which is 2331). Be Mobile Network. o Derm Phone 2 – (+267)77583003 (this is an Iphone). Orange Network. • The major cellular networks are BeMobile, Orange and Mascom. • The derm phones can be used for personal use. If you also wish to have your home phone, contact your network provider to “unlock” your phone. Then, you purchase a Botswana SIM card after arrival ($10) that will make your phone function in Botswana. • Calls and texts from your phone cost Pula, calls and texts in do not. • To recharge your phone – buy small scratch cards from airtime vendors – which are located literally everywhere there is foot traffic (check with anyone selling drinks on the sidewalk, etc). Scratch off a panel on the back to reveal a code. Follow instructions on the card to enter the code and add the airtime to your SIM card. Do this before leaving the vendor, to verify they did not sell you a fake card. • Some vendors can now send minutes directly to your phone without a scratch code—you will get a text instantly from Orange confirming the transaction. Again do this before leaving the vendor. • To check how much money you have left on the phone, press *155# and send or *121# and send. • To add data to the Resident iPhone dial *148#, send, follow the prompts to add data to the phone. • Phone calls during the day ~ P1/minute • Text messages ~ 25 thebe. • Land lines will often only call land lines. • AFTER YOU USE THE DERM PHONE, PLEASE MAKE SURE TO PASS IT TO THE NEXT PERSON WITH MINUTES & DATA LOADED. • If you have issues with loading data or phone functioning - it is always best to ask a local for help first. There are a few tricks that can be difficult to pick up. We do not advise going to the Orange store for help because they frequently give misinformation. Inform Dr Williams if you are having phone issues.

Internet • WiFi at the flats. The WiFi at Pilane is not as reliable or fast as in the US. If you are having problems with the internet functioning please email Liza to let her know. • There are a few internet cafes around town where you can pay to use more reliable internet. You can also print/fax/copy there. Most residents prefer to use the free wifi at The Daily Grind (M-F 7am – 7pm, shorter hours on the weekends) and Main Deck (open daily until 10p).

Flats and Communal Living Accommodation in Gaborone is in BUP housing called Pilane Court (Address: Plot 154/155, Ext 9,Gaborone) which is a safe and comfortable complex of flats. It is more similar to a hostel than a hotel. It is about a 10 minute walk from PMH and 5 minutes to Main Mall. We try very hard to house all Penn

11 visitors – even if that means occasional overcrowding. It is less expensive and potentially more fun so be prepared to “go with the flow”. You may be asked to change rooms to accommodate others based on gender (i.e. the “Derm Room” is called this because our storage closet is located there. You may or may not be staying in this room). • Cleaning and maintenance. Housekeepers clean and do the laundry and ironing daily. If you encounter any maintenance problems please tell Liza Rissik asap, who will tell the maintenance people. If you break something, replace it and let Liza know. • Food. Food costs and cooking may be shared communally or more individually-based, depending on the preference of the group. Cost sharing is usually done on an honor system basis so please remember to contribute without being asked. • Water. The quality of the tap water varies with droughts and other issues… You can ask Liza Rissik her advice regarding this when you arrive, but as a rule, we recommend drinking bottled water. Due to rationing during droughts, at times, Pilane court has not had water for a day or two. Residents often showered at Jack's Gym during those times (buy a day pass-- decent work out facilities too). • Power. Gaborone is dependent on South Africa for most of its electricity, and infrastructure problems have led to severe power shortages. Power outages are common, and from time to time, plots are restricted to a daily electricity limit, after which the power goes out. • Security. There is a nighttime security who remains on the premises throughout the night.

Rules of the Flats 1) Be neat – there are a lot of people living in a fairly small place 2) Food is shared - contribute to the purchase of food without being asked. 3) Leave bread, jam, peanut butter, and tea in stock for the maid in your flat. 4) Internet Etiquette: there are a number of persons living in the flats, please be aware of the time you are using the internet. Streaming video will slow down the internet for everyone and generally will not work. Download videos prior to your arrival in Botswana 5) When you leave, it is customary to give a “Bone Sela” to the maid who has looked after you. The suggested rate is P100 per month pro rate, so for 6 weeks the Bon Sela is P150

Money Matters • The unit of currency is the Pula. 1 Pula ~ 8-10 to the dollar. There are 100 thebe in a Pula. • Cost of living is overall less expensive than in the US. Some things cost more but many things cost much less. Food tends to be about the same. • Notify all banks and credit card companies of your travel plans. • ATMs are generally the cheapest and easiest way to get cash. o Check the back of your card to make sure that it is on the PLUS network. Cirrus, NYCE, and MAC cards are not generally usable. o If possible, make sure your pin number is 4 digits long. Some ATMs do not accept longer codes. o You can withdraw money from an ATM using your credit cards, but you pay high interest. o If you have trouble with ATM, try the ATM at the Gaborone Sun Hotel - it has been reliable. Credit Cards: Many places in Gabs accept credit cards (hotels, supermarkets), but you need cash for things like taxis and for most things outside of Gabs. American Express is usually not accepted. There are currency exchange offices (e.g. Travelex) in the airport and at some malls like Riverwalk. It is requires a passport. The fees and exchange rates are generally poor. Money wire. As a fallback you can always have money wired to the Main Mall Barclay's Bank.

Transportation There are several available methods of transportation. Public transportation can be identified by their BLUE license plates. Remember when giving directions, use easily identified places. Most do not know the street names, but will use the destination as the road name, for example “the road to Gabane.” • Taxis o Most residents travel by taxi. It is easiest and safest to program numbers of cab drivers into your cell phone. Taxi drivers who often work with the Penn visitors are saved in the Resident phones – Samson is the most commonly used.

o Taxis are often available at the bus terminal, main mall, Riverwalk and Game City. o Approximate examples of fares (from Pilane) . A trip within the city costs P30, and at night the cost is around P30-40. . Riverwalk 40p; Game City 40-50p; Airport Junction 40- 60p . Airport 90-120p; Mokolodi 75-120p • Combis are crowded minivans that are a common way for locals to get around. Talk to folks on the ground to ask how to use them. The cost of a ride is P3.50. Combis are an adventure and a true Botswana experience. • Buses. You can get to any sizable city in Botswana by bus. Typical times are: Gabs-Francistown, 6 hours (P83/person). Francistown-Maun, 6 hours (P40/person). Buses can be found on the north side of the bus station, and they generally leave every half an hour or when the bus is full. The destination is written on the front of the bus. Buses can be crowded and have no AC. Get there early to get a seat. • Plane Travel. Air Botswana: Office on Main Mall. Flights to Jo/burg, Maun, Kasane. South African Air: Offices in Broadhurst and Game Malls. • Travel agents/Tour Guides o **Refer to the folder on the Google Drive marked “Travel Advice” or email Dr. Williams for travel advice/tips o Tim Race: He leads outstanding camping trips to the Kalahari. He has all of the necessary equipment. Price is on the higher side.

Safety You will generally feel safe in Botswana. The government is stable, and the Batswana are uniformly friendly and helpful. Reported crimes are mostly robberies (usually cell phones), and car break-ins at the foot of Kgale Hill. Crime is rarely against a person, apart from snatching a cell phone from your hand. Remember your street smarts. In August 2015 there was a break-in at Pilane Court, and an iphone was stolen. There is now a security guard on site at night. . After dark, do not walk by yourself and use the streets rather than the paths. . BE CAREFUL WITH YOUR PHONE AT ALL TIMES. Do not walk with your phone out or visible in your pocket – it will get snatched. Iphones are incredibly desirable and often stolen! . “Smash and grab” crime is the common - thieves will smash the window and grab valuables off the seat or out of your hand even with the car in motion. Do not use your cell phone in the car. . NO DRIVING YOURSELF. Car accidents pose a particular risk to travelers in developing countries and Botswana is no exception. In addition, it is not a good idea to be on intra-city roads after dark, where many experienced drivers have accidents. . From the US Embassy: “Wild animals pose a danger to tourists. Tourists should bear in mind that, even in the most serene settings, the animals are wild and can pose a threat to life and safety. Tourists should use common sense when approaching wildlife, observe all local or park regulations, and heed all instructions given by tour guides.” . PLEASE, be careful and make smart choices in Gabs and when traveling. Your choices and their consequences affect the future of this program and there have been foolish actions in the past that have put the program in jeopardy. Example: one participant went camping in the Kalahari by himself when it is recommended to always take two cars and there is a significant lion issue. . If in doubt, check things out with Liza Rissik, and always tell her when you are leaving town.

Restaurants, Entertainment, and Travel See the Appendices for a list of restaurants, bars, malls, and other entertainment. There are also some travel recs for weekend trips. For more info, see the Google drive or email Dr. Williams. Note, travel is permitted over the weekends as long as: 1. You tell Liza Rissik your itinerary, and 2. It does not interfere with your clinical work or keeping up with administrative work.

INTRO TO CLINICAL WORK

In the Botswana rotation, you are responsible for caring for sick patients and running dermatology clinics in a resource limited setting. As a provider, it is an incredible opportunity for growth as a clinician and as a person. It is also a big responsibility with unique challenges, and is HARD WORK.

There are a few important things to note: 1) Support. You will always have support – locally and/or remotely. Do not feel rushed, you have time to learn and time to think about what you are doing and to ask for help.

2) Job description. Your job description may not be what you are used to as a U.S. resident (example: stocking supplies). Remember: you are here to 1) learn and 2) take care of patients. Be flexible… the motto should be, “how can I help?”

3) Adjusting. It takes time to adjust to the ‘foreign’ system.

• Triaging care is difficult to do – all actions should be necessary and a good use of your limited resource. It is challenging to learn what to work up and what to leave. So…prepare for a steep learning curve (we will guide you), and be open-minded (crucial). Be prepared for the frustration of dealing with a new system, inefficiencies, lack of accountability, meds being out of stock, inability to get some lab tests, and deaths that would not occur in the US. Working with local healthcare workers can be frustrating due to different levels of knowledge, work ethic and interest in patient care. All of this is superimposed on jet lag. Most people require about two weeks to get past the frustrations and inefficiencies that are part of our work in Botswana. Changes are being made slowly by evolution not revolution. By the middle of your rotation you will feel in pretty good control and by the end regret that you are leaving.

4) Work ethic and expectations. Most residents who come to Botswana are curious and dedicated. However, there have been issues with some residents who view the rotation as a break from normal residency responsibilities and accountability. It is important to know – you are these patients’ doctor. Your diligence and skill is providing them care that they would not be getting otherwise. Our advice: o Take advantage of this unique learning opportunity! Read about your patients, follow up details, and be curious. You will see and learn an incredible amount. It is rare that you will again have the opportunity to be fully integrated into the local healthcare system in a developing country – don’t miss out on your chance to learn. o Do your best to not pass work off to the overworked physicians on the ground or the next resident. o Specific expectations are listed below. If you have questions about the expectations, please ask Dr. Williams / Forrestel to clarify. Dr Jereni, your local supervisor and either Dr Williams/Forrestel, your remote supervisors, will complete the form following your rotation and send it to your program director.

LEARNING OBJECTIVES AND EXPECTATIONS FOR RIG RECIPIENTS

The objectives of the rotation and the specific expectations are listed below. This will be used to evaluate you at the end of the rotation with input from Tori, Amy, and Dr. Jereni, so be sure to read through the expectations. You will not be evaluated on each point individually, but rather the evaluation will contain general feedback and comments. The evaluation will be sent to your program director at the end of the rotation.

Patient Care Objectives:

- Provide direct patient care to patients in both inpatient and outpatient clinic settings at Princess Marina Hospital and Outreach Clinics.

Expectations: Be available for work at Princess Marina Hospital or the outreach clinics 8-5pm Monday-Friday. Rarely, an urgent consult will need to be seen after hours. Consults: Carry two dermatology phones with you at all times and answer calls or messages promptly (within a few hours maximum) Consults: See new consults after clinic the day of consultation. Follow up consults should be seen as frequently as is appropriate for the severity / complexity of the case (very sick patients may need to be followed and seen over the weekend when possible) Review cases with faculty (in person or via email, WhatsApp, or phone): 1) if there are any questions about the case, and 2) All complex cases Complete administrative work and documentation required for patient care in a thorough, timely fashion. This is often done in the evenings or on the weekends. Keep medical supplies organized and in stock, which includes: 1) Refilling the supply closet in the hospital and biopsy bag from the Pilane closet. 2) Emailing the incoming resident 2 weeks prior to their arrival to tell them which supplies they should try to bring, 3) Keeping the liquid nitrogen refilled for cryo days

Medical Knowledge and Learning Objectives: - Increase knowledge of how to diagnose and treat tropical and HIV related skin diseases. - Increase understanding of diagnostic, therapeutic and practice challenges in a resource‐ limited setting.

Expectations Read about your patients’ diagnoses and attempt to support management decisions with relevant literature.

Interpersonal & Communication skills Objectives: - Understand the role of the visiting trainee / clinician - Communicate effectively with the multi-disciplinary care team

Expectations Deliver at least one PowerPoint presentation to medical / pediatric hospital residents Pay careful attention to training during orientation week and then give thoughtful and thorough training to the incoming resident.

Professionalism Objectives: - Become familiar with local cultural customs and apply to patient care to provide respectful and responsible care - Recognize that in this unique practice setting, professionalism includes reading available materials to guide clinical practice and extends into promptly answering emails or texts, and being accessible by phone.

Expectations Treat all patients and health care providers with respect and humility. Be punctual for clinic.

Return phone calls, faculty emails, and texts in timely fashion. - Phone calls / texts – within a few hours - Emails – within 1 day. Keep phones charged with sufficient data for patient care Read and review training material to become proficient for patient care

THE SETTING – PRINCESS MARINA HOSPITAL

There are parallel public and private health systems in Botswana. Each system has their own set of hospitals, clinics, and physicians. Care in the public sector is completely free for Batswana, including laboratory testing, hospitalization and meds. There is also a very important third “health system”-- the traditional healer. Most Batswana seek some of their care from traditional healers in addition to the public system. UPenn works in the public sector, and has been based in Princess Marina Hospital (PMH) since 2004. PMH is the main tertiary referral hospital in southern Botswana. Every day, many of your patients will have traveled hours (or even overnight) to come see you.

Until recently there had been no medical school in Botswana, therefore, around 90% of the physicians in the hospitals are from outside Bots. Most physicians do not speak Setswana, and rely on the nurses for translation (just like us).

The University of Botswana (UB) med school started its first pre-med class in August 2008. Prior to this all Batswana medical students spent their clinical years at hospitals outside Botswana. Botswana started its own internship program in January 2007 and the first residencies (Peds and Medicine) started in 2010. There are now also residencies in EM, Family, and Pathology. UPenn and dermatology are heavily involved in helping with training UB students and residents. Currently all UB med students, and peds, family, and medicine residents rotate through the dermatology clinic, and you are responsible for helping to teach them basic dermatology they can use in Botswana.

Other programs working at PMH Harvard has a large research laboratory that does primarily AIDS-related research. Baylor College of Medicine is an important provider of outpatient pediatric HIV care and medical education at their facility – the Botswana-Baylor Children's Clinical Center of Excellence.

Set-up of Medical Wards at PMH During your rotation you will be see inpatient consults in the medical wards at the hospital. The wards are: medical (male and female), two surgical wards (M and F), ortho (M and F), oncology, isolation, pediatric, and an ICU. Wards are divided into “cubicles” of patients, which contains around ten patients each, most on hospital beds or on the floor. The most tenuous patients are in Cubicle 3 (“high dependency cubicle”), right in front of the nurses’ station. Medicine generally runs about 20 beds over the maximum.

Medical teams are called “firms” on the medical wards (also given color names – Pink Team, Blue Team, Green Team). Some of the firms are designated as part of the teaching program and each has at least one PMH intern or Medical Officer (MO). A PMH MO is a physician who finished medical school and internship, but s/he has not done a residency. An MO could be a new graduate or been practicing for years. Firms are headed by an attending, called a “specialist.” A “specialist” has completed a residency and often have an area of focus. Penn has full-time clinical specialists at PMH and Penn medical students and residents are fully integrated into the firms. MOs and interns are the primary caretakers of the patients, and specialists supervise them with morning rounds three times a week and afternoon rounds on the other two days (after the specialists’ AM clinic). MOs, interns, and you round on patients every day (except the weekends, unless on call), and perform all blood tests and procedures.

ROTATION STRUCTURE

Dermatology residents are available to see patients from 8-5 Monday – Friday and to see urgent consults over the weekend (rare).

Outpatient Clinics • Tues – Fri from 8am until the last patient is seen (usually around 2pm). • Tues, Wed, and Fri are at PMH • Thursdays are outreach clinics, which occur in 4 locations outside of Gaborone. Residents set up transportation to these sites through PMH weekly. • Patients come early in the morning to register and are given numbers to wait in line to be seen.

Consults • Inpatient consults are seen after clinic • Consults will come in through the derm phones, or residents / nurses from the wards will bring patients to clinic. When patients are mobile, it is best to ask providers if they can come to clinic to be seen.

Monday Admin • Mondays are admin days to catch up on work in the dermpath lab, calling patients, completing documentation, etc.

Dermpath • Residents read all slides themselves, review with the local dermatopathologist, and do tele-consultation with Carrie Kovarik for complicated path cases.

Documentation and Patient Follow Up • There is no electronic medical record (apart from one to order labs and check lab results). Notes are written on paper charts that patients bring with them to clinic. • Because of this, keeping track of patients (particularly if they are complicated) and following up results is logistically difficult – compounded by residents rotating every 4-6 weeks and the fact that there is no internet access during clinic. • We have devised a documentation system that is largely based on a Google drive account (BUPDerm). The system consists of: • Patient encounter log – excel spreadsheet documenting all patients who are seen in the clinic or on consults. You upload this to the Google drive each week. This is also an AAD grant requirement. • Biopsy log – additional tab on the excel spreadsheet to document each biopsy performed, track where the slides are in process, and document clinical plans after biopsies are read. • Biopsy Powerpoints – residents make a powerpoint for every biopsy performed containing clinical information, differential diagnosis, and photos. These are used for clin-path correlation when Dr. Kovarik or the local pathologist read the slides. For the cases that are referred to Dr. Kovarik, photos of pathology are then added to the powerpoint by Dr. Kovarik (when the slide scanner is working) or by the resident (when the scanner is not working). Also used for formulating patient care plans. • Clinical Photos – are uploaded each week to the drive • Complicated patients – there is a Google Doc with a list of complicated patients. When a complicated patient comes into clinic, it can be very difficult and time consuming to track down information. One must often: 1. Look up labs in IPMS, 2. Read through prior notes on the paper chart. 3. Look at the biopsy log for past reads, 4. Search the BUP Gmail account for up to date discussions on workup and plan… this can take time and things fall through the cracks. This list is meant to consolidate these resources so the process does not need to be repeated each time by new residents and communicate To Dos and future plans.

Handoffs • As you can imagine, with so much resident turnover, handoffs are KEY to caring for these patients. • There is a guide to handoffs (and what they should cover) in the “Clinical Guide”

Dermatology Supplies

• Many supplies used in clinic are brought from the U.S. by residents and faculty coming to Botswana. The dermatology resident keeps these organized, ensures they are not expired, and tells the incoming residents what to bring (if possible) 2 weeks prior to departure. • The resident also manages the cryo and ensures it is refilled for our 4 days of cryo per month.

Teaching • Residents give a powerpoint lecture to local clinicians at 2 outreach sites: Lobatse and Mochudi • See what topics have been assigned by Dr. Forrestel / Williams. There are previous lectures for most of these topics on the Google drive by prior residents but you are expected to review and make improvements as needed.

Research Studies • Currently, there are several ongoing research studies at PMH on cutaneous lymphoma, Kaposi Sarcoma, and albinism. Dr Williams will inform you if you need to do anything to assist with these projects.

Resource Limitations • There are many areas in which you will notice resource constraints compared to the US. Some of the most visible / common things you will encounter are: • Meds are frequently out of stock at PMH. If they are out of stock, patients can either buy them out of pocket at a private chemist (or if they have Medical Aid it will pay for it), or you have to pick an alternative med in stock at the pharmacy. • When referring patients, you must be specific with what you want the other specialist to do, and often advocate for your patients. Local physicians are overworked, sometimes undertrained, and patients with urgent issues often require extra direct outreach to get them seen promptly. • Diagnostic testing – options will not be as robust as you are accustomed to. Basic examples of what we do have: o RFT (renal function test), FBC (CBC), LFTs, UA, RPR are easily obtained o HIV testing takes about an hour and is easy to do o Variable - must check during your rotation to see if available: ANA, ENA (dsDNA and other rheum markers), protein electrophoresis (SPEP) o FNAs are easy to get and very useful o For malignancy r/o there are no CT scans – in place, we typically use CXR and U/S abdomen +/- pelvis to look for masses, lymphadenopathy, and hepatosplenomegaly o Skin biopsies – process works reasonably well to get an H&E done (fasted turnaround time is 2 weeks but can often take longer), but special stains are more difficult and often lead to long delays. We try to limit biopsy only for cases that would affect management, and where therapeutic trials are not a good option o IT IS ESSENTIAL THAT YOU LEARN AND UTILIZE BASIC BEDSIDE DIAGNOSTICS including KOH (for tinea and deep fungal infections), Tzank smear (for HSV/VZV, crypto, molluscum) and mineral oil for scabies. There is a bedside diagnostics folder with lectures on the google drive which you are required to review. o Microbiology – the quality of the lab is not nearly as high in the U.S. which limits utility of bacterial swabs and severely limits utility of tissue cultures for fungus and micobacteria. AFB and gram stains tend to work a bit better though.

High Yield Prep Work • If you have time to do reading beforehand, it can be very helpful to help you hit the ground running. • In the “Clinical Guide” Handbook, there is a section on Specific Disease Tips – take a look at this before you arrive. • Reviewing derm textbooks on KS and HIV-related skin disease is high yield. • Learn how to do bedside diagnostics including slide smears and touch preps. There is an excellent JAAD CME on this: https://doi.org/10.1016/j.jaad.2016.06.035 • Log in & register for http://africa.telederm.org/ .There is a curriculum of high yield cases from Africa Global Health

• Before traveling to Botswana , we highly recommend that you review global health training material from Unite for Sight: http://www.uniteforsight.org/global-health-university/. In particular, the online (free!) courses on Cultural Competency, Volunteer Ethics, International Research, and most of all the general Global Health course, are very useful. • This is an HIV webstudy program that may be useful in preparing for the trip: https://www.hivwebstudy.org • In spite of good intentions, international health work that does not follow global health best practice principles can be wasteful, unethical, and harmful. Worst practices can create barriers to patient care, exacerbate health disparities, and violate concepts of social justice and human rights. Although our practices are not perfect, we try to be mindful of the best practices of global health. A large portion of what you will learn from your experience in Botswana will be about global health and how to adapt your practices from home to be ethical and useful within the local healthcare system. This means listening to and learning from the local physicians

BACKGROUND ON DERMATOLOGY IN BOTSWANA AND GLOBAL HEALTH DERMATOLOGY RESOURCES

In 2008, when Dr Kovarik started working in Botswana there was no local dermatologist - only a medical officer who had some dermatology training who ran a clinic at PMH. Dr Kovarik started sending dermatology residents and faculty to support this medical officer with teaching, training and clinical care. Then Dr Kovarik formulated the idea for the Resident International Grant and obtained funding from the AAD to support 15 residents per year to rotate in Botswana which allowed continuous dermatology support and an innovative educational opportunity for residents. Over the years there have a number of different local dermatology providers with varying levels of training who have come and gone at PMH - medical officers, dermatology specialists, Cuban dermatologists and some trained dermatology nurses. There has also been periods where no local dermatology provider was present and care was only being offered by rotating derm residents. As a resident, Dr Williams rotated during a time of no local support. The clinic was in disarray and patient care was suffering. She was inspired to take on the critically needed role of a full time local dermatologist in Botswana’s public health system. In Jan 2016, straight after residency she accepted a Ministry of Health position being paid as a local physician because there was no US funding available to support a dermatologist in Botswana. She worked full time in Botswana for 2.5 years and established many systems to improve quality of care in dermatology clinic. When she transitioned back to working in the US in May 2018, there was no replacement available so she continued to run the clinic remotely by supporting the rotating derm residents. In Sept 2018, Dr Bwanali Jereni was hired as the new dermatology specialist at PMH. It has been a slow transition to hand over all clinical care functions to Dr Jereni because Dr Williams performed many functions that are above any beyond what is expected of a local Ministry of Health physician. We will continue to slowly pull back resident and faculty support of the dermatology clinic to allow the local care systems to kick in. We are aware that the quality of care in dermatology may decline with the transition away from a US level of care, but in the end it is most important to build a sustainable model for dermatology care in Botswana that is not reliant on foreign physicians. One of the hardest parts of global health is knowing that better care is possible but not being able to provide it! But we encourage you to focus on the big picture improvements of dermatology care in Botswana that are happening - in 2015 there were no local dermatologists in the country. Now, in 2019 there are two African dermatologists and 3 Cuban dermatologists working across the country - this is a huge victory! Your experience and expertise can assist in the continued growth of dermatology knowledge among providers across Botswana and this is exciting!

Currently, Dr Williams, Dr Forrestel and Dr Kovarik (all faculty at the University of Pennsylvania, run the UPenn Dermatology Global Health Program and the AAD RIG Program on top of their regular clinical duties. Through a mix of funding sources, Dr Williams/Forrestel are able to spend time abroad doing global health work for a few months per year until 2020. Building global health into a dermatology career is challenging because sustainable funding sources for global health work are limited outside of large research grants. There are never guarantees that you will continue to get to do funded global health work as a faculty member - but we hope to be able to! For those interested in making global health a part of their long term career, feel free to reach out to Amy/Tori/Carrie with questions. We recommend that you join GLODERM -the International Alliance for Global Health Dermatology (https://gloderm.org/), a new organization for

19 global health dermatologists which will help you find mentorship and opportunities in the future. We have always welcomed past RIG recipients with an interest in returning to volunteer in Botswana and tried to accommodate them whenever possible - feel free to reach out if this interests you!

APPENDIX 1. ENTERTAINMENT AND TRAVEL

Restaurants All easy to get to by car- none of these are really inexpensive, but are so by USA standards. Andy Schafer rating (actually he did not go to them all): o The Daily Grind: Closest to an American coffee shop in Gabs - one block away from Pilane on Independence Ave. Open 7am – 7pm M-F and shorter hours on the weekend. Free Wifi. o PMH cafeteria: Back open and good as ever. Huge plates for <30 pula. They run out of food by ~1-1:30pm. o Fresh Cafeé: Right next to the Choppies near ICC flats. Delicious breakfast, lunch, and brunch. Good coffee as well. o Bull and Bush:*** English pub, excellent ribs, excellent pizza, music and disco dancing some nights, monthly trivia contest. o Gaborone Yacht Club:*** At the Gaborone Dam. This place was a favorite for “sundowners” on a Wed or Fri after work (closed to public on other days). Take a cab, and watch the sunset over the water. Enjoy the wine and beer and the best hamburgers in town. o Chutneys and Embassy***: Very popular Indian restaurants o Maharaja:*** Indian restaurant next to the Bull and Bush o Moghul: ****Indian, less expensive than the Maharaja. o AVANI: ** expensive, but excellent Sunday brunch. Mahogany : upscale restaurant with piano player. Happy hour on weekdays from 6-7pm with half-price drinks. o Newscafe: ** mid range, upscale, South African franchise, at present seems to be the place for the young professionals (esp Thursday evenings o Sanitas: ****Tea house: favorite for Sunday brunch and for lunches. Located in a garden center that has many plants to purchase. Nice setting. Free wifi. o No 1 Ladies Coffee House: ***excellent desserts and food. Free wifi. o Mokolodi:****there is a very nice restaurant at the game park about 15 km down the road to Lobatse. One of the nicer restaurants in Gabs. Can get some exotic foods such as kudu steak, ostrich, impala steak, etc. recently started doing breakfasts. o Basilico: new italian restaurant near Pilane. It is one of the nicer restaurants in Gabs. Requires advanced reservations. o Grand Palm Hotel: The Beef Barron is one of the nicer restaurants but also expensive. There is also a good Chinese restaurant at the hotel. o Red Lantern: Excellent Chinese Restaurant in Broadhurst – 3908514. Will also do take out orders which you have to collect. o Ashoka: African Mall. Indian food. Well worth a visit for curry lovers o Caravella: Portuguese. One of the best restaurants in Gabs, expensive. o Main Mall: o Café Pie Time: free wifi, cheap pies and pizzas. Recommended. o Main Deck: free wifi, upstairs, bar with food and outdoor seating o Nandos: popular South African chain, chicken dishes. o Debonnaire Pizza ***(they actually deliver) o Riverwalk Mall: o Milky Lane: Only ice cream store in Gabs (has outlet at game city also) o Equatorial Coffee ** Company: lunch and coffee o Simply Asia: Thai/noodle dishes. Very good.

o Dros: pub food and great place to have beers and watch a soccer match. o Mugg and Bean: best coffee drinks, excellent breakfast and lunch. They make their own muffins, cakes are for sale and are huge but excellent. o Rodizo’s – Brazilian Steakhouse; on Thursdays, all you can eat meat for 140 pula which includes a free glass of wine o Pizza Hut o Airport Junction: o Ocean Basket: known for its great seafood dishes. o Cappuncinos: nice café/restaurant. Free wifi. Good salads and pizze o Café Europa: great café with free wifi and excellent pizza. o Rhapsody: upscale restaurant that turns into a dance club with dj on fri/sat nights.

Malls The term “mall” is used for any collection of stores. There have been two relatively modern malls built in the past decade in Gabs, Riverwalk and Game City. o Main Mall: Center of town near the government buildings. This is a 10’ walk from the hospital. and about a 20’ from ICC, and a 3 min walk from Pilabe Court. Past its prime, but some atmosphere and is undergoing a revival. Outdoor mall with a lot of stalls where people sell crafts, vegetables, etc. You can bargain. Good place to walk from the hospital to get a pie or pizza for lunch, or for basic groceries (Spar, Payless). o BBS Mall: Near the private hospital in Broadhurst. Also about a 20’ walk. Also more atmospheric that the modern malls. There is a good second-hand bookstore at this mall that is above the Woolworths. It has much more atmosphere than Riverwalk or Game and on the weekends is full of stalls where you can bargain for all sorts of things o Riverwalk: Multiplex movie, restaurants, grocery, liquor store, hardware store, computer store, electronics store, internet café, book store (expensive), clothing and sports stores. o Game City: Largest mall in Gabs, near Kgale Hill. All mall-type stores, plus Game – a huge Walmart type place where you can get most everything. o African Mall: near the main mall, small but also with some atmosphere. o Airport Juntion: newest and nicest mall – most like a traditional american mall

Movies New Capital Cinemas has location at Riverwalk and Game City. These theaters tend to play the large blockbuster Hollywood movies, other bad movies from the US, and some Academy nominated movies. Tickets are around P25. Movies show from Wednesday to Sunday. Movies are assigned seating – like going to the theater.

Sports o Gyms are found in Gaborone. Most Penn people go to Jack’s Gym in the Village Mall or I-Towers (accessible by combi). The gym has a great pool, cardio equipment, weights, and classes. The staff is uniformly nice and helpful. You can pay by day, week, or month. Student rates available as well. There is also a gym in the Broadhurst area and at the Gaborone Sun hotel. o Virgin Active is the newest and fanciest gym. But far away in Airport Junction. o Zumba: It has become part of the Pilane Court experience to go to evening Zumba classes held at the school next door. These classes are fantastic and a lot of fun. It is only 30 pula for a one hour class from 5:30-6:30pm. A Saturday morning class is sometimes available as well at 8:30am. The current tenants at Pilane can provide more information, and you can check out their Facebook page as well (Zumba in Gabz). o Tennis: Tennis club at Gaborone Sun and National Tennis Center (have to join either of these). One can use the courts at the University of Botswana for free.

o Squash: Squash courts at the Gabs Sun, the National Squash Center (behind the National Stadium) and Jacks Gym. o Running: National Stadium is open, and you can often see young Batswana training there. You will see few runners on the street. There is also nice running behind the stadium on packet sand – towards the Cricket pitch and around the UB stadium and old airstrip. You will need some guidance, but you can take a very long run in the bush by going past the cricket pitch. o Football: Spectator games nightly on the dirt fields between the National Stadium and the University. If you are lucky there will be some national team games at the stadium. o Rugby: The Gaborone Rugby Club is located near the Village Mall. o Cricket: There is a national cricket pitch behind the main football stadium o Golf: The Club is walkable from the Gabs Sun. Greens fees/club rental/pull cart rental cost about $25. There is a beautiful course ~15km north of the city at Phakalane ~ $50 o Ultimate Frisbee: Mon and Thurs at 7pm at the Gaborone Sports club in the Village. 30 pula because it is played at the private club. Great turnouts with lots of ex-pats.

Night Life . Bars o Bull and Bush: “English pub” in north part of Gabs. Large screen television to watch sports, pool, and great pizza. Mix of ex-pats and Batswana. Penn usually enter at least one team. Quiz night is last Wednesday of the month. . Karaoke: sometimes available at the Red Lantern restaurant . Dancing: o Che Ntemba in Mogoditshane- P20 to enter, and a mix of local music and American pop. Filled mostly with locals. Great scene, but bring ear plugs o Bull and Bush becomes a dance club late on weekend nights o Boulevard in Phakalane

Day trips You can hire a cab for all or part of a day to take you to these places In Gaborone: o Kgale Hill: Located in the SW part of Gabs. It is a moderate hike, about 3 km to the top. Great 360-degree view of Gabs from the top. Look out for the baboons. Note: Cars have been broken into when left at the foot of the hill. You can leave your car in the nearby parking lot at Game City and walk to the hill. Because of a mugging, the USA embassy has advised against climbing Kgale. It is ok to go, but go in a group and do not bring anything of value. o Gaborone Dam: The only body of water in Gabs! Fun place for a picnic. Can check out the yacht club for sundowners. Can also rent 4-wheelers for a ride around the dam. Sometimes you need a permit, but sometimes an “exception” will be made. There have been some muggings there lately so check it out with some of the locals before going o Mokolodi Game Preserve: Located a mere 15 kilometers outside Gaborone on the road to Lobatse. Game includes various antelopes, giraffe, zebras, warthogs, white rhino, and elephants. This is a nice and convenient “first safari”. You can take guided tours and attend various educational programs on site. It is about P35 for a one-day pass. Make sure you save time to eat at their restaurant. They also have a Sunday champagne brunch + game drive combo which is fun. You can now also walk with cheetahs at the park - but currently you can only do this on weekday afternoons so it is difficult to arrange with the derm clinic schedule. o Gaborone Game Park: About a 5 minute drive or 20 minute walk from the flats. It is certainly not very exotic by African standards (antelope, warthogs, zebras and ostrich)., but very pleasant place to spend an afternoon. GGP does not require a 4-wheel drive car (but can only

go in with a car) and only 10 Pula. There are several Game View sites where one can sit and enjoy the peace and bird sounds. Make reservations to go to the park on the weekends. o National Museum: A block from PMH. Nice museum, but not very big. o Art: Thapong Visual Arts Center is a cooperative of artists’ studios, located near Jack’s Gym, across from the old prison in Gaborone Village. Open daily until 6:30pm, Thapong features an amazing collection of resident artists’ works that are best described as contemporary African sculptures and paintings. The studios are in shanties scattered around the cooperative, and the artists are always more than willing to talk with visitors. Ask for Barnabus. o Craft Center: A group of craft stores in the Broadhurst section of town. Open during the week and on Sat until 15:00. Here you will find a bunch of ex-pats buying crafts, clothes, and eating at the Italian deli. There is a wine shop that sells Biltong (local dried meat). o Local theatrical groups and dance troupes often have events and it is worth looking out for these as they are normally very good and well attended. Liza Rissik tries to circulate the information when she hears about them.

Around Gaborone: o Thamaga: Small village outside of Gabs known for its pottery. It is a great place to buy souvenirs. Approximately 30-45 minute drive along the road to Gabane, and can catch a bus there at the bus station. o Gabane: village close to Gabs: can visit the Kgotla (tribal meeting place). There is a pottery studio run by Martin (very friendly). Sell beautiful handmade pottery. Highly recommended. o Oodi: There is a weaving cooperative that one can tour and get local weaving. Easily included on a drive to Mochudi. o Otsi: There is a crafts cooperative run by Camphill. A very nice ½ day trip. Can also take in the Vulturary outside of town. There is a nice little Barantani Lodge in the village where one can stop for a cold drink. A cheese factory is across the road from the village o Mochudi: Interesting local museum with a great view of the valley o Molepolole: On the way to the Kalahari. Can visit Scottish Livingstone Hospital which was started by Dr Alfred Merriweather missionary /doctor, his wife still lives out there. She started the Shepherd School with 8 children, today there are over 500.

Longer trips Please refer to the folder marked “Travel Advice” on the google drive for more info or tips on travel from Dr. Williams and prior residents. Especially helpful for how to get discounted rates for your travel. With most trips, there are accommodation options for luxury, standard comfort, budget, and camping. o Trips to Chobe, Victoria Falls or Namibia are generally not possible over a weekend and would have to be done with vacation time at the end of your stay. o Khama Rhino Sanctuary in Serowe: About a 4 hour drive to the north. It is a good overnight trip and one can stay in a self-catering chalet in the rhino sanctuary. Easily done in a weekend. o Okavango Delta: This inland delta is the biggest tourist attraction in Botswana. The camps in the delta are very expensive, but are all-inclusive and the most unique part of Botswana. You will have to pay ~$300 for a charter flight to get from Maun to the camps in the Delta but you will not regret it. Great animals, birds, and night sounds of the tree frogs plus incredible scenery. You can also stay outside the park in Maun and do day trips into the delta for a much lower cost. It is possible to do a trip to the Delta over a weekend, but it is a very short costly trip due to the high price for flights. o Chobe Game Preserve/Victoria Falls: In northeast part of Botswana. Chobe has the highest concentration of elephants in Africa. The evening sundowner cruise on the Chobe river is a must. Please request to be on a large boat for safety. The sunsets are amazing and you will see the game in a totally different environment. Elephants swim across the river and the hippos

wallow in their pods. The Chobe River Lodge has self catering chalets either 2 or 3 bedded. In the past there has been a UPENN rate that was negotiated by Gill but it is uncertain whether this is still valid. Day trips to Victoria Falls are available. o Madikwe: Right over the border in South Africa. You must make reservations ahead. There are lots of lodging options and different price levels, but none that are “cheap”. It is an absolutely fabulous (and romantic) weekend getaway. Just outside of Madikwe is Masela Sela at a far more reasonable price, around P600 a night, which includes a game drive each day + an extra one if you pay for it.. Most people have preferred to stay in the park. You can view the lodges at: www.madikwesafaris.com. UPenn has negotiated a discount rate at Tau but this will only be provided for last minute bookings made within 7 days. They also require proof of affiliation with UPenn – an ID badge or recently a copy of your program letter from Dr. Kovarik or a letter written from Dr. Williams has worked. Also check out http://www.bushbreaks.co.za/ for good last minute deals. o Jo’burg: Five hours by car from Gabs, or you can take a Flight Connect bus from Riverwalk to Joburg airport. Make sure you get a very, very detailed map, as street signs are nearly nonexistent, and it is very easy to get lost (and your trip could be hours, hours long). Northern suburbs are beautiful and safe, but Jo’burg proper is known to be very, very dangerous. Great restaurants and great B&Bs. Some activities include Soweto Township tour, the Apartheid Museum, and various other cultural activities. Remember the Tlkoweng border closes at 22:00. o Pretoria: On the way to Jo’burg, but an hour closer. During season the Jacaranda trees that line the streets are UNBELIEVEABLE. There is also an excellent zoo. The Kruger museum is well worth it for an understanding of South African history. o Khutse: gateway to the Kalahari, known for its extreme isolation, picturesque desert scenery and plentiful predators – namely lions. This is also an expensive destination even for camping. There is a new lodge just outside of Khutse that is very nice and the place to go if you are not a camper or if you cannot arrange for a camping trip. Remember safety first - one should never do this trip without an experienced guide or other persons due to the dangerous predators. Always go with more than one vehicle. o Tuli Safari Lodge: It is very worthwhile trip. The scenery is beautiful and the lodge is very nice. One can stay inexpensively in a great tent site on the banks of the Limpopo river. About a 5-6 hour drive from Gabs.

APPENDIX 2: ABOUT BOTSWANA

Map of Gaborone can be found on Google Drive  Overview Map of Gaborone

Location Botswana is a land-locked country, slightly smaller than Texas, in the center of Southern Africa. The Tropic of Capricorn runs through it. It encompasses 600,370 square kilometers, of which, only 15,000 square kilometers has water. It is predominantly flat to gently rolling tableland, with the Kalahari Desert to the southwest, occupying 87% of the territory.

Climate The climate is semiarid with cool winters (June-August) and hot summers (December-February). The country suffers from periodic droughts given the desert climate. The rainy season in the summer is characterized by intense, brief, dramatic thundershowers. Average daily temperatures range in January from 22oC/71oF – 33oC/91oF and in July from 5oC/41oF –19oC/66oF. Typically there are long periods of bright sunshine daily throughout the year with clear skies and low humidity. Summer days can be quite scorching, particularly before the rains come. In the winter

months a fleece or sweater is a must in the morning and at night. Most buildings do not have heating and there is little air conditioning.

Demographics Botswana is a sparsely populated country of 1.8 million. Because of the uninhabitable Kalahari Desert, the population is heavily concentrated along the eastern corridor, from the capital city of Gaborone to Francistown. Of the population, 35% are 0-14 years old; 61% are 15-64 years old; and only 4% of the population is older than 65 years. Most people are Tswana (or Setswana), and the remaining are Kalanga (11%), Basarwa (formerly known as “San” or “bushmen” which is considered a derogatory term) (3%), and other (7%) which includes Kgalagadi and white.

Botswana has one of the highest HIV/AIDS infection rates is the world with approximately one quarter of the population infected. The effects of excess mortality due to HIV/AIDS, has caused life expectancy to drop to ~50 years, infant mortality to increase to 45 deaths/1,000 live births, and to lower population and growth rates. In addition, the socioeconomic impact is immense including loss of skilled laborers and teachers, loss of per-capita household income, and a high number of orphans.

Nationality The people of Botswana are Batswana, and one person from Botswana is called a Motswana. Using the term “Botswanan” will identify you are an uninformed foreigner.

Religion 70% are Christian, 7% have indigenous beliefs, and 20% have no religion. Note too that many Batswana may also mix some African Traditional Religious or Badimo beliefs into their other religious practices (e.g. consulting medicine men for advice).

Economy Since its independence in 1966, Botswana has maintained one of the highest rates of socioeconomic and infrastructure growth. It was transformed from one of the poorest countries in the world to a middle-income country with a per capita GDP of $14,100 in 2008 but fell precipitously in the recent economic downturn. AIDS is threatening this remarkable economic growth. Diamond mining drives the economy, and accounts for >1/3 of the GDP and 75% of export earnings. Other important industries include tourism, financial services, subsistence farming, and cattle. Recently large amounts of gas have been found in the Kalahari. Despite this stability, poverty remains an important concern, as there is a large gap between rich and poor, unemployment is officially around 24% and unofficially close to 40%, and women head approximately half of households.

Cattle Beef is a major export in Botswana and cattle are highly valued. Wealth is often measured by the number of cattle owned. Cattle posts are places where boreholes are drilled down to the level of groundwater. Generally the cattle roam free (“free range beef”) at the post and are not fenced (they don’t wander too far from the water) but they are looked after by a Modisa (herder). It is considered rude to ask someone how many cattle they have; it would be like asking someone how much money they have in the bank.

Kgotla The kgotla is the traditional meeting place in villages where disputes are brought before chiefs and issues of public interest are discussed. Kgotla is both the name of the meeting place (a

semicircular enclosure usually under the shade of a tree), and the name for the meeting, and serves as both the village council and the tribal court. Traditionally only men took part in these tribal meetings, but now women may attend. The kogtla is an early example of democratic principles at work. Anyone who attends the kgotla may speak. (For this reason, some kogtlas may meet for a number of days.) Ultimately, however, the kgosi (chief) makes the final decision. Kgotlas still play an important part of decision making and government in the villages outside of Gaborone. If you work in a village, it is important for you to visit the kgotla and introduce yourself to the local leaders.

Birth Dates Many older or rural Batswana don’t know the exact date of their birth. Births in rural areas are often linked to a season or a holiday or a memorable local event. Also, Batswana may give the year of their birth rather than their present age when asked how old they are.

Body Language Like much of the world, Batswana do not have the same concept of personal space as Americans and may stand closer than people do with one another in the US. It is also not uncommon for men to hold hands. You may also encounter a slight variation on the traditional western handshake, in that Batswana will shake hands, grip thumbs (with the same hand), and then shake hands again. Note that not everyone in Botswana makes eye contact when communicating with strangers. In particular, it is customary for young women and girls, particularly in rural areas, to not make eye contact when speaking to strangers.

Botswana Time Like much of the rest of the world people are not nearly as time driven as in the U.S. So do not expect meetings, cabs, etc. to be precisely on time. Just relax and enjoy the saner lifestyle. But know too, if you are going for a short amount of time and have very specific but time dependent goals, you are less likely to be successful in meeting them. The Botswana time zone is CAT (Central Africa Time) and is either six (daylight savings) or seven hours ahead of Philadelphia/EST.

LGBT Officially, both female and male same-sex sexual acts are illegal in Botswana but prosecution is rare. Same sex couples have no legal recognition. Certainly there is a lesbian and gay community in Botswana, but in general homosexuality is not publicly accepted. Note that it is common for heterosexual men in Botswana to hold hands publicly, so do not assume that two men who are holding hands are a romantic couple.

Holiday Date English name Local name 1 January New Year’s Day Ngwaga o mosha 2 January Public Holiday Varies Good Friday Labotlhano yo o molemo Varies Easter Monday Varies Ascension Day Tlhatlogo 1 May May Labour Day 1 July Sir Seretse Khama Day 19 July President’s Day 20 July Public Holiday 30 September Independence Day Boipuso 1 October

25 December Christmas Keresemose 26 December Boxing Day 27 December Boxing Day The first Monday after Christmas is also a Public Holiday.

APPENDIX 3: LANGUAGE (SETSWANA)

English is the official language, but Setswana is the national language and is widely used (79%). Many older Batswana only speak Setswana. Young children are taught in Setswana until 4th grade so small children also may not speak English. In general, foreigners are not expected to know any Setswana, and therefore, even a few phrases of Setswana will be very well received and appreciated. Speaking Setswana will show your desire to learn about Botswana, and it will definitely help you in the hospital. Liza Rissik can also have a language instructor give a Setswana lesson at Pilane Court, if this is requested. The few words/phrases everyone will find of use are marked with two asterisks.

Setswana belongs to the African Bantu language group, deriving from the same roots as Zulu in South Africa, Shona in Zimbabwe, and many other languages in the region. Setswana was first written down by Robert Moffat (ancestor to the Superintendant of Princess Marina) when he translated the Bible into Setswana in the 1830s. Since Setswana was first written by an English speaker, most of the language is phonetically spelled for English speakers, with a few notable exceptions (G is nearly always pronounced as H and TH as T). There are other languages spoken in Botswana, notably the language of the San of the Kalahari and Kalanga, spoken by a minority group from the north of the country.

After Botswana’s prosperity started in the 1970s, newly independent Botswana invested heavily in primary schooling (just as it did in primary health care), so most of your patients under 30 will have had at least a few years of primary school and will be able to have a conversation with you in English, though they will be more comfortable in Setswana if (as is likely) it was spoken at home. The English fluency of Batswana over 30 varies tremendously, but age is a good guide, with the elderly least likely to be able to communicate in English, and many middle-aged Batswana able to understand only some English and then only when spoken in a Commonwealth/British accent. You may recognize some cognates to English, German, or Dutch, most of which entered Setswana during and after the Protectorate period, generally via South Africa’s English and Boer settlers, but also through neighbors in the former English colony to the northeast, Rhodesia, now Zimbabwae, and the former German colony to the West, now Namibia.

Essential Setswana

Hello ma’am/sir Dumela mma/rra How are you? (How’s it?) Le kae? How are you? (more formal) O tsogile (pronounced TSO-HEELE) jang? I am fine/We are fine Ke teng / Re teng (use of the plural shows respect) I am fine (more formal). And you? Ke tsogile sentle. Wena?

My name is … Ke nna … Leina lame ke (your name) Who are you? (also the name of the national O mang? identity card and number) I am from Philadelphia in America Ke tswa Philadelphia ko America Generic: Goodbye (also “all is well”) Go siame (HO- SA- YAME) Saying goodbye as one departing Sala sentle (“Stay well”) Saying goodbye as one staying Tsamaya sentle (“Go well”) Yes E No Nnyaa Thank you Ke a leboga / Re a leboga (pronounced LE-BO-HA) Tanki (borrowed from Africaans) Excuse me Sori May I (please) have some water? (Ke kopa) metsi

APPENDIX 4: HIV IN BOTSWANA

Needle Stick Exposure and PEP The risk of needle stick exposure is quite real. Most sticks occur when you are rushed or stressed. In the event of a potential exposure immediately stop working, take your first dose of PEP, and notify your clinical supervisor. We will take care of you.

Please note, just as in the US, you must report all needle stick exposures and other risks – follow the notification steps given to you by Liza Rissik during your orientation. Your information can be kept confidential if you choose, but we (Amy/Tori) like to know the circumstances surrounding incidents so we can work to prevent them and to make sure that you receive appropriate follow-up on return. You will also receive an emergency dosage of PEP to keep with you at all time during your rotation in case of an exposure. Be sure to read through the PEP protocol that Liza goes over with and make sure you understand what to do if exposed.

HIV/AIDS in Botswana HIV/AIDS surveillance has been taking place since 1990 in various settings in Botswana. The prevalence is close to 40%, making it the country with the second highest percentage of adults infected. As a result, one-third of children are “AIDS orphans.”

A number of factors have contributed to this prevalence:

Excellent roads with the vast majority of the population located in a relatively small geographic area. Customarily, men have a minimum of 4 homes and have at least one sexual partner in each location. These homes include the village dwelling or homestead, usually the principle home; the cattle post; lands for arable farming; and the urban home. Rapid movement between the homes, resulting in only narrow differences between rural and urban HIV infection rates. Premarital sex and teen pregnancy is fairly normal.

Botswana’s Response to HIV/AIDS In the past five years Botswana has created and put into place an extensive HIV prevention and treatment program. This has required the development of an entire HIV management infrastructure since very little was in place. As with all other aspects of health care the program is free to all citizens (they have national health care). Anti-retrovirals (ARV’s) can only be prescribed or changed at one of the treatment sites (we can continue medications on admitted patients).

At the present time there are over 32 ARV sites around the country caring for over 75,000 patients. This is remarkable given that there was essentially no treatment as recent as 2005. There are over 17,000 patients registered at the clinic at PMH making it the largest HIV clinic in the world!

Who is targeted for the ART program? All infected patients get started on ARV’s if they have a documented HIV (+) test. Pregnant woman are also a target group for treatment. First line therapy in Botswana is Combivir and efaveranz or nevaripine or doltragavir(women of pregnancy potential).

HIV Testing in Botswana: As of March 2004 HIV testing has been done on an “opt out” or routine basis. Therefore extensive counseling and an in-depth consent procedure is not required. Every patient of undocumented HIV status should be tested (unless they decline). This is one of our outcomes measures. We cannot manage HIV successfully if we do not identify those infected before they are seriously ill. Rapid testing is readily available in every hospital setting. There is no need to confirm HIV positive tests (whether done by rapid method or ELISA) with a western blood testing since the prevalence is so high in Botswana. Patients can now also be sent to a special clinic set up with the sole purpose of testing for HIV and counseling positive patients on what to do next. The UB residents and nurses can help you refer patients to this clinc.